Your plan medical group

One team working together to provide you the best health care possible.

Our members receive primary care, specialty physician care and access to hospitals and other facilities through several physician groups called plan medical groups (or PMGs). These physician groups or PMGs are comprised of doctors, specialists and other providers who are located throughout San Diego and southern Riverside counties. We have ten plan medical groups:

Sharp Rees-Stealy Medical Group
Sharp Community Medical Group
SCMG Palomar Health Medical Group
SCMG Graybill North Coastal
SCMG Palomar Health Medical Group Temecula

SCMG Inland North Medical Group
Children’s Physicians Medical Group
Greater Tri-Cities Independent Physicians Assn.
Optum Care Network-North County SD (formerly Primary Care Associates Medical Group)
Independent Providers Network

Plan networks and plan medical groups

PMGs are affiliated with plan networks. We have four plan networks — Premier, Performance, Value and Choice. These networks cover specific geographic areas across San Diego and southern Riverside Counties. You receive covered benefits and services from physicians who are affiliated with your PMG and who are part of your plan network. Below you can see our networks and their associated plan medical groups.

Plan Medical Group	Premier	Performance	Value	Choice
Sharp Rees-Stealy Medical Group (SRS)
Sharp Community Medical Group (SCMG)
SCMG Graybill North Coastal
Sharp Community Medical Group - Inland North (SCMG Inland North)
SCMG Palomar Health Medical Group Temecula (SCMG PHMG Temecula)
SCMG Palomar Health Medical Group (SCMG PHMG)
Rady Children’s Health Network (RCHN/CPMG)
Greater Tri Cities IPA (GTC)
Optum Care Network-North County SD (formerly Primary Care Associates Medical Group)
Independent network

Primary care physicians and plan medical groups

Your primary care physician (PCP) coordinates your health care. Most PCPs are contracted with only one plan medical group. Your PCP is affiliated with both a plan medical group and a plan network. In some plan networks, you may select a PCP who is contracted directly with the Sharp Health Plan instead of directly with a PMG. In this instance, if you choose one of these PCPs, your PMG will be “Independent.” To find out which doctors are affiliated with your PMG and network, refer to your provider network directory.

What to consider when you want to keep your doctor or specialist

You receive covered benefits and services from physicians who are affiliated with your plan medical group (PMG) and your plan network. To keep your doctors, make sure you choose a benefit plan where your PCP or specialist are in the same PMG and network.

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How referrals work

PCPs provide our members with appropriate services or referrals to other plan providers such as specialists. Your PCP will typically refer you to a plan provider within your plan medical group.

If covered benefits are not available from plan providers affiliated with your PMG, you will then be referred to another plan provider to receive those covered benefits. Availability of plan providers are assessed based on your specific medical needs, provider expertise, geographic access and appointment availability.

You are responsible to pay for any care not provided by plan providers affiliated with your PMG. However, there are exceptions.

You can get out-of-network services covered if your PCP or PMG has prior-authorized the service or it is an emergency. If you receive health care services from doctors without receiving required authorization from your PCP or PMG, you will be responsible for payment of expenses for these services.

Remember, benefits and services are only covered when provided or authorized by a PCP or PMG except for emergency or out-of-area urgent care services.

Provider & pharmacy directories

Download the provider and pharmacy directory that lists all primary care physicians, hospitals, urgent care centers and pharmacies in your network. If you are unsure about which provider network you belong to, you can find the name on the front of your member ID card.

Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you choose a plan. Call your prospective doctor, medical group, independent practice association, or clinic, or call Customer Care at 1-800-359-2002 to ensure that you can obtain the health care services that you need.

What to ask your care team

Every time you talk to a health care provider — PCP, specialist, a nurse or another person on your care team — we recommend asking these three basic questions:

What is my main problem?

What do I need to do?

Why is it important for me to do this?

If you have more questions

When can I ask questions?

Anytime! For example, you can ask your PCP questions during your visit, before or after your physical exam or medical test. You can ask your nurse when you are having your vital signs taken. You can also call the Sharp Health Plan Customer Care at 1-800-359-2002.

What if I ask and still don't understand?

Let your PCP, nurse or provider know if you still don’t understand. You could say, “This is new to me. Will you please explain that to me one more time?”

I'm nervous asking questions. What should I do?

Know that you aren’t alone, and it’s OK to feel nervous — everyone wants help when it comes to understanding health information. When you see your doctor, specialist or nurse, take your time in asking questions. You should never feel rushed or embarrassed if you don’t understand something. It’s OK to ask your provider as many times as you need to.